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Falls Risk Screening: Within the last 12 months
|
|
|
Has this patient had any falls in the last year?
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Falls Comments
|
|
Does the patient have worries about falling or feel unsteady when standing or walking?
|
Falls Comments
|
|
Does the patient have any medical conditions making them a risk for falling?
|
Medical Conditions Increasing Risk for Falling
• • •
|
|
Does the patient use any assistive devices?
|
Assistive Devices Patient Utilizes?
• • •
|
|
Is the patient a falls risk at this time?
|
Falls Risk Interventions?
• • •
|
|
Falls Comments
|
|
|
Immunization Screening
|
|
|
Has the Patient Received the Current Seasonal Influenza Vaccine?
|
Date Influenza Immunization Received (Month & Year)
|
|
Has the Patient Received the Pneumonia Vaccine?
|
Date Pneumonia Immunization Received (Year & Month)
|
|
PHQ-2 Depression Screening: Over the last 2 weeks
|
|
|
Screening Completed?
|
|
|
Little Interest or Pleasure in Doing Things?
|
|
|
Feeling Down, Depressed or Hopeless?
|
|
|
Total PHQ-2 Score
|
|
|
Screening Answer
|
|
|
Depression Comments
|
Depression Interventions
• • •
|
|
MIPS Vital Measures to Obtain: BP, Ht, Wt, BMI
|
|
|
**BMI (Document EVERY Visit)
• • •
|
BMI Interventions
• • •
|
|
**Controlling High Blood Pressure (Document EVERY Visit) (Only for pts with a dx of HTN)
• • •
|
HTN Interventions
• • •
|
|
Diabetic Mellitus
|
|
|
Diabetic Neurological Evaluation
|
|
|
Neurological Evaluation
• • •
|
Medical Reason Neuro Exam Not Completed
|
|
5.07 Monofilament Test Displayed
• • •
|
|
|
Soft Touch Sensation - Left Foot
|
Soft Touch Sensation - Right Foot
|
|
Sharpdull Sensation - Left Foot
|
Sharpdull Sensation - Right Foot
|
|
DM Neuro Interventions
• • •
|
DM Neuro Exam Comments
|
|
Diabetic Footwear Assessment & Education
|
|
|
Evaluation of Footwear
• • •
|
|
|
Does the patient wear appropriate shoes?
|
|
|
Does the patient need inserts/orthotics?
|
|
|
Did the patient have prior foot care education?
|
|
|
Can the patient demonstrate appropriate self-care?
|
|
|
Diabetic Foot Education Performed.
|
Pt Advised to have Diabetic Foot Exam Annually.
|
|
Elder Maltreatment Screening: Within the last 12 months
|
|
|
Elder Maltreatment Screening Complete
|
|
|
1. Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?
|
|
|
2. Has anyone prevented you from getting medical or personal items, or from being with people you wanted to be with?
|
|
|
3. Have you been upset because someone talked to you in a way that made you feel shamed or threatened?
|
|
|
4. Has anyone tried to force you to sign papers or to use your money against your will?
|
|
|
5. Has anyone made you afraid, touched you inappropriately, or hurt you physically?
|
|
|
6. Question for Provider
|
|
|
Screening Results
• • •
|
|
|
Elder Abuse Exam Comments
|
|
|
Well Woman Exam
|
|
|
HPI
|
|
|
Age:
|
Pain (0-10 Scale)
|
|
LMP
|
G:____
|
|
P:____
|
A:____
|
|
Hysterectomy
|
___ Year if yes
|
|
Last PAP date
|
|
|
Mammogram within last 2 years
• • •
|
General Comments Mammogram
|
|
Have you had a colonoscopy in the last 5 years?
|
|
|
Review of PMH
|
Changes
|
|
Review of FMH
|
FMH
|
|
Sexually Active
|
|
|
Number of Partners
|
Male/Female/Both
|
|
Smoker
|
Drug Use
|
|
Review of Systems
|
|
|
Review of Systems
|
|
|
General [-]
|
General
• • •
|
|
General Comments
|
|
|
Skin [-]
|
Skin
• • •
|
|
Skin Comments
|
|
|
HEENT [-]
|
HEENT
• • •
|
|
HEENT Comments
|
|
|
Neck [-]
|
Neck
• • •
|
|
Neck Comments
|
|
|
Breasts [-]
|
Breasts
• • •
|
|
Breasts Comments
|
|
|
Cardiovascular [-]
|
Cardiovascular
• • •
|
|
CV Comments
|
|
|
Respiratory [-]
|
Respiratory
• • •
|
|
Resp Comments
|
|
|
GI [-]
|
GI
• • •
|
|
GI Comments
|
|
|
Urinary [-]
|
Urinary
• • •
|
|
Urinary Comments
|
|
|
Genital (Female) [-]
|
Genital (Female)
• • •
|
|
Genital (Female) Comments
|
|
|
Periph. Vasc. [-]
|
Periph. Vasc.
• • •
|
|
Periph. Vasc. Comments
|
|
|
MSK [-]
|
MSK
• • •
|
|
MSK Comments
|
|
|
Neurological [-]
|
Neurological
• • •
|
|
Neuro Comments
|
|
|
Endocrine [-]
|
Endocrine
• • •
|
|
Endo Comments
|
|
|
Psychiatric [-]
|
Psychiatric
• • •
|
|
Psychiatric Comments
|
|
|
Physical Exam
|
|
|
General WNL
|
General Abnormal
• • •
|
|
General Comments
|
|
|
HEENT WNL
|
HEENT Abnormal
• • •
|
|
HEENT Comments
|
|
|
Skin WNL
|
Skin Lesion
• • •
|
|
Skin Comments
|
|
|
Neck WNL
|
Neck Abnormal
• • •
|
|
Neck Comments
|
|
|
Cardiovascular WNL
|
Cardiovascular Abnormal
• • •
|
|
Cardiovascular Comments
|
|
|
Lungs WNL
|
Lungs Abnormal
• • •
|
|
Lungs Comments
|
|
|
Abdomen WNL
|
Abdomen Abnormal
• • •
|
|
Abdomen Comments
|
|
|
External genitalia WNL
|
External genitalia abnormal
• • •
|
|
External genitalia comments
|
|
|
Vagina WNL
|
Vagina abnormal
• • •
|
|
Vagina comments
|
|
|
Cervix WNL
|
Cervix abnormal
• • •
|
|
Cervix comments
|
|
|
Uterus
|
Uterus Abnormal
• • •
|
|
Uterus Comments
|
|
|
Adnexa WNL
|
Adnexa abnormal
• • •
|
|
Diagram
|
Adnexa comments
|
|
Bi-Manual Exam
|
|
|
Chaperoned By:
|
|
|
MSK WNL
|
MSK Abnormal
• • •
|
|
MSK Comments
|
|
|
Breasts WNL
|
Breasts Abnormal
• • •
|
|
Breasts Comments
|
|
|
Neuro WNL
|
Neuro Abnormal
• • •
|
|
Neuro Comments
|
|
|
Extremities WNL
|
Extrem Abnormal
• • •
|
|
Extrem Comments
|
|
|
STD (GC/Chlamydia/Trich):
|
Yeast/BV
|
|
PAP
|
HPV
|
|
Hemacult
|
Results
|
|
Mammogram
|
Results
|
|
Colonoscopy
|
Results
|
|
Bone Density
|
Results
|
|
Labs
|
Lab Results
|
|
Other Screening
• • •
|
Other
|
|
Patient Education
• • •
|
|
|
Diagnosis
• • •
|
Plan
|
